Provider Demographics
NPI:1427893734
Name:PETERSON, KATHRYN WINSLOW (LPC-MHSP)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:WINSLOW
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPC-MHSP
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:WINSLOW
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC-MHSP
Mailing Address - Street 1:912 CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-5124
Mailing Address - Country:US
Mailing Address - Phone:512-417-6012
Mailing Address - Fax:
Practice Address - Street 1:912 CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5124
Practice Address - Country:US
Practice Address - Phone:512-417-6012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-27
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6071101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health